Impact of Angiography-Derived Physiological Patterns of CAD and Optimal Hemodynamics Post-PCI on Residual Angina

BACKGROUND: Focal stenotic coronary lesions, as defined by the invasive pullback pressure gradient index (PPGI) measured before percutaneous coronary intervention (PCI), are associated with less residual angina than diffuse lesions as assessed by the Seattle Angina Questionnaire (SAQ). OBJECTIVES: This study aims to investigate the interaction between a lesion's baseline functional phenotype (focal vs diffuse) and the physiological success of PCI, as defined by a post-procedural Murray-based angiography-derived flow ratio (μFR) above 0.90 (adequacy of flow AOF), in correlation with angina status at 2 years. METHODS: The ASET-Japan study enrolled 203 patients with chronic coronary syndrome. The baseline functional disease pattern and the achievement of AOF (post-PCI μFR > 0.90) were analyzed as potential factors influencing the rate of residual angina at 2 years. RESULTS: SAQ scores were obtained in 186 patients. The median follow-up duration was 771 days (Q1-Q3: 752-805). AOF was achieved in in 61.3% (114 of 186; 95% CI: 54.1-68.0), with the μFR post-PCI differing significantly by the lesion's baseline phenotype (diffuse 0.92 ± 0.06 vs focal 0.94 ± 0.04; P < 0.001). At 2-year follow-up, patients in the AOF group with preprocedural focal vs diffuse disease had significantly better angina frequency scores (99.2 ± 3.3 vs 94.8 ± 11.7; P = 0.007), and less frequent residual angina (6.7%; 4 of 60; 95% CI: 2.6-16.2 vs 22.0%; 11 of 50; 95% CI: 12.5-34.9; P = 0.040). CONCLUSIONS: In patients who achieve AOF during PCI, the baseline functional phenotype of treated lesions in patients with or without angina at follow-up is significantly different. A global physiological assessment integrating AOF and the baseline functional pattern of disease is potentially useful to accurately predict residual angina post-PCI. (Acetyl Salicylic Elimination Trial Japan: The ASET Japan Pilot Study ASET-JAPAN, NCT05117866).